tv CNN Newsroom With Kate Bolduan CNN April 12, 2021 8:00am-9:00am PDT
the intensive care unit. the second part of my clinical duties is i see patients in the outpatient setting in the office, in the clinic. where i evaluate, diagnose, and treat patients close to 50% of the patients, the new ones that i see in the clinic, are referred by other cardiologists because these patients can sometimes have pretty complex medical conditions. and then the third part of my clinical work is i perform procedures in a procedural suite we call the cath lab, i measure pressures inside the heart and inside the lungs. and sometimes i will also take small biopsy samples of the inner lining of the heart for diagnosic purposes. >> given that you deal with a number of patients who could be really sick, do you ever have patients that will pass away? >> so i work with a tremendous
team at northwestern and my colleagues save countless lives. but unfortunately, many patients do die. >> do you ever have any involvement in determining the tau cause of death? >> oh, yes i do. >> you could explain? >> sure. one of the most important parts of my job, in fact, is to determine what's wrong with a patient including if they do actually die, how did they die? and so there are a number of ways in which i participate in that role of figuring out what happened to a patient, how did they die? >> are you involved in any hospital committees that have as their purposes determining the cause of why people die or pass away? >> sure. i do. so outside of being in the trenches, taking care of the patients at the bedside and
figuring out what is going on and trying to discern what might have happened, i also participate on a committee. that means regularly and what we do is we review all of the cases in the cardiac intensive care unit. we look at any near deaths and any deaths. and we review looking at the medical chart and all the evidence to try to figure out what might have happened for quality purposes to figure out if there was something else we could have done. and also to improve just our overall knowledge of the field. >> do you have experience with patients who sometimes pass away during what is called clinical trials? >> yes. so i also participate in clinical trials where we try to determine if a certain medication or a certain device is worthy of being approved to help patients. in the course of clinical trials, sometimes there are deaths. and so in my role, i have sat on committees and our purpose on that committee is to review any death that's do occur. look at all the evidence to
figure out, number one, why did the death happen? and number two, sometimes this is one of the more important parts to distinguish was it a cardiac cause or was it for a reason that is not related to the heart? >> we're bringing this further home to this case. do you have experience with cardiac patient who's die from what we call low oxygen? >> most certainly i do. >> could you tell us about that? >> yeah. so because i am a cardiologist who takes care of patients in the intensive care unit, having low oxygen levels is not uncommon. a lot of disease processes can cause it. and low oxygen levels can be very detrimental. some of our patients require ventilators and respirators. and so in the course of caring for the patients, sometimes they succumb to their illness because their body is not able to get enough oxygen. >> do you ever have to determine
cause of death in the heart transplant context? >> yes. so in the field of heart transplant, what happens is when you get a phone call that somebody has died and they want to be an organ donor. so what i need to do is look at the case from afar, but try to look at all the records as closely as possible to really sort out how that individual died and if there is any issues related to their heart or other parts of their body to make absolutely sure that that heart would be a good match for my patient who we're trying to help. and so that's another element where you have to be really meticulous as you go through. you don't want to miss anything here, right? i mean the stakes are way too high. >> we heard from a couple of pathologists in the trial. does your job require you to work with pathologists?
>> yes, it does. >> in what way? >> so i work with cardiac pathologists closely, more so than other general cardiologists. i take buy iopsy specimens. i send those to the pathology to review under the microscope. we have conferences and talk about autopsies. one of the things that i have learned over the years and i've been taught this by the card i can imagine pathologies is why they can look under the microscope and give us very important information, i work with a world renowned pathologist who remind me every day, please tell me as much clinical information as you can. put it in clinical context because how i diagnose and interpret what i see under the microscope is very much influenced by the clinical story. and so we work very closely
together because my pathologist looks under the microscopes and sees the tissue at that level. i can provide all the clinical information, the time lines, et cetera, so we can truly get it right. >> just a little bit more background, dr. rich. have you published in the field of cardiology? >> yes. >> can you characterize what kinds of publications and how many? >> sure. so to date i've published more than 200 combined be attracts and book chapters. the topics are wide ranging in the field of cardiology from coronary artery disease, hypertension which is high blood pressure, congestive heart failure and pulmonary hypertension. >> and what is pulmonary hypertension? >> pulmonary hypertension is high pressures that are specific to the blood vessels in the lungs. all right. so when the blood flows from the
heart to the lungs, the pressure is high in those blood vessels, we refer to that as pulmonary hypertension. >> doctor, would you generally describe for the jurors what is cardiology as a science? >> sure. so cardiology is the study of the heart, the most basic level. it's the study of how the heart functions, what happens when the heart develops disease. pretty much everything heart related and how it interacts with the rest of the body in order to sustain life. >> how do you go about assessing a patient with a cardiology issue? >> sure. so when you assess any patient with or without a cardiology issue, but in this context, a cardiology issue, you typically begin by meeting the individual in the office, taking the history, doing a detailed physical examination, reviewing all the medical records and the charts, looking at past
procedures, tests they may have had. sometimes speaking to other colleagues who you are caring for that patient with together. and then sometimes ordering your own tests for evaluation and diagnostic purposes. >> are some of your patients referred then from other cardiologists? >> yes. because of my specialty in advanced heart disease, close to half the patients who are -- i'm seeing in at the office as new patients have been referred to me by other cardiologists. typically in the community or in the region and i will assist them in consultation to figure out what is going on and what we need to do to help that individual. >> in the icu, do you take care of patient who's have problems beyond the heart? >> yes. so, you know, it's interesting. as a cardiologist, i think part of the important reasons why they require of us to do that internal medicine residency training is because no organs
work in isolation. and so my patients who have heart disease who also require the intensive care unit, they will usually have issues with many other organs, lungs, kidneys, sometimes brain, liver. and so you really have to be adept and have a really good understanding of not just the heart but all the organs of the body and really how they interact. >> let's talk about your role in this litigation? how did you become to be involved in this case? >> i was contacted by the state of minnesota and i was asked as a cardiologist to review the facts of this case to help determine how mr. george floyd died. >> have you been compensated by the state for the bulk of the work you've done on this case? >> not up my time here at trial, i have not received
compensation. >> and why not. >> well, probably for a couple of reasons. mostly i felt that my job as a cardiologist could really help inform the facts of this case. every year i take on a number of professional activities without compensation. i actually think it's a duty of our field. and so in this case, i felt i could make a meaningful contribution to the medical field. >> so for your compensation for your time while here at trial, you are being compensated at $1200 a day? >> $1200 a day while i'm missing work back at home. >> can you tell us what work you did? what did you review before forming opinions in the case? >> sure. so i was provided with a lot of evidence to look through. but mostly i looked through the
medical records. interviews, all the videos that were provided to me and the autopsy report. >> did you review some journal articles as well? >> yeah. as i was formulating my opinion and creating my expert report, i also looked up journal articles and embedded them into my report for references. >> have you formed any opinions in this case, to a reasonable degree of medical certainty as to the cause of mr. floyd's death? >> yes, i have. >> would you tell us your opinion or opinions? >> sure. in this case, mr. george floyd died from a cardiopulmonary arrest. it was caused by low oxygen levels and those low oxygen levels were induced by the prone restraint and positional asphyxiation that he was subjected to. >> let's discuss your opinion,
dr. rich, and let's start with a general discussion of the circulatory system and the heart. so i'd like to talk about the right side of the heart, left side of the heart and all the other parts of the heart. would you start off and just tell the jury, remund them, what are the adioli? >> sure. so you might remember hearing about this. but the avioli are the grape like structures that are at the very bottom of the lungs. the the avioli is where the gas transfer occurs. oxygen gets into the bloodstream and then the carbon dioxide that needs to leave the body cross that's same barrier into the avioli so when we take our deep breath out, that's how the carbon dioxide is removed. >> again, what does a heart do in the body? >> what does the heart do?
>> it is the major pump of the body. the best way to think of the heart in my view is to actually think of it as two pumps. sort of a right side and a left side. >> so if we start with the right side of the heart, after all that blood got pumped to the body and coming back to the part, blood is always returned to the right side of the heart. so this is now blood that presumably does not have much oxygen in it and it needs to get more ofrm general. so the right side of the heart, its job is to pump blood to the lungs to the aveoli. it can pick up the oxygen that it doesn't have right now and it can deliver carbon dioxide and other acids and waste products to be expelled from the body. once that blood from the right side of the heart has picked up the oxygen that it needed, it sends it to the left side of the heart. now the left side of the heart gets all the glory.
because it is what then pumps all of that oxygen and nutrient rich blood to the entire body, meaning, to the lungs, kidneys, brain, muscles, to deliver oxygen. every organ, every tissue needs oxygen in order to function. and then once that process occurs, it repeats back to the right side and so forth. >> and what happens if the lungs can't deliver sufficient oxygen to the heart? that is if there is a low oxygen situation? >> okay. well, the heart is only as good as the fuel that it is provided with. so when that right side of the heart sends blood to the lungs and says okay. can i have some oxygen please? if there is no oxygen there or not enough oxygen there, there is nothing the heart can do to extract more from the lungs. so it has to take that deoxygen yated blood that, blood that does not have enough oxygen and pump it to the left side of the
body. the left side of the body says this is what i v i'm going to pump now. what happens is if the lungs don't give enough oxygen to the body, the heart that has to pump insufficiently oxygenated blood to the tissues of the body and that's when problems occur. >> returning to your opinion, cardiopulmonary arrest caused by induced positional asphyxia. what caused the low level of oxygen in the case of mr. george floyd? >> well, in his case, it was the truly the prone restraint and positional restraints that led to his asphyxiation. in a nutshell, he was just simply unable using all of his muscl muscles and less pieration and chest wall and accessory muscles of respiration.
he was trying to get enough oxygen and because he was unable to because of the position he was subjected to, as we just discussed, the heart thus didn't have enough oxygen either which then means the entire body is deprived of oxygen. >> so low oxygen induced by positional asphyxia. did you consider other possible causes of mr. floyd's death? >> sure. i tried, of course, to be as thorough as possible. i focused mostly on two other potential causes. number one, is whether there could have been a primary heart contribution to george floyd's death. and the second was whether a drug overdose could have caused his death. >> so, doctor, would you tell the jury what is a primary heart event? >> sure. a lot of things can injure the
heart. for example, if you do not take in enough oxygen, that will injure all of the organs including the heart. when i use primary heart event, i mean something that originated from the heart itself. so, for example, a heart attack. one of the arteries of the heart just subtly got blocked completely and a heart attack occurred. or the heart just without any explanation, nothing else secondary inducing it went into a serious ventricular arrythmia. the bottom part of the heart, the part that we were talking about that needs to pump blood to the body went into a chaotic rhythm on its own. if any of those things happened, then i would consider that a primary heart issue. not being caused or secondary to something else. >> so you consider whether or not mr. floyd might have passed away from a primary heart vent
or a drug overdose. did you reach an opinion or conclusion to a reasonable degree of medical certainty as to whether either those two causes explained mr. floyd's death? >> yes, i did. >> would you tell us your opinion? >> sure. after reviewing all of the facts in evidence of the case, i can state with a high degree of medical certainty that george floyd did not die from a primary cardiac event and he did not die from a drug overdose. >> thank you, dr. rich. would you tell us what evidence or facts, documents, what did you look at to help you to reach that conclusion about primary heart event or drug overdose? >> sure. the three aspects of the evidence that i spent the most time reviewing were mr. george floyd's medical records, the videos at different angles from the day that he died on may 25th, 2020, and the autopsy
report. >> so the medical records, videos and the autopsy report. >> yes. >> let's start with the medical records then of those three. would you tell the jury what you were looking for in the medical records? >> sure. so you get the medical records. usually pretty thick. but you take it one page at a time. and at the outset i was looking to see if he had been diagnosed with any medical conditions. sort of the first step, you know, kind of what you do with a patient in the office. what medical problems do you have? i was looking to see initially what diagnosis george floyd may have previously been diagnosed with. >> and what were your take aways then from having looked at the medical records and done this assessment? >> so at that level, i felt pretty confident that mr. floyd had three medical problems. number one, he had hypertension,
high blood pressure. number two, it appeared to me that he may have suffered from anxiety. and, three, it looked like he also struggled with substance abuse. >> other than those three conditions, did mr. floyd have any diagnosis of heart disease while he was still alive? >> no, he did not. >> so you said you looked at the medical records not only for diagnosis or pre-existing conditions, but also for evidence of medical encounters? >> correct. >> and by that you mean hospital visits, clinics, et cetera? >> emergency room visits, exactly. >> what did you find in that regard? >> so this is in my opinion was a really important part of the review as well. because every time mr. floyd had an encounter with a medical professional, i view that as an opportunity to see if there was
any signs, symptoms, whatsoever, even subtle, that could have indicated, for example, that he had anything going on with his heart. and so at the emergency room visits, he had one prolonged hospitalization. i really tried to take a look at everything. i looked at any opportunity i could to see if he ever complained of chest pain which he did not. palpatationses, a fluttering sensation of the heart. i review all of the documented physical examinations of his heart so see if there were any abnormalities noted. there were not number murmurs, nothing found. i looked at all of his labs that get sent to see if there were ever any cardiac markers of injury which he did not have. i reviewed his ekgs and his other tests. i tried to be as thorough as possible. i view this as -- i view as a clinician as actually being a detective. and our job is to try to figure
out what might be going on even if it it's not overtly stated so in the chart. >> you would tell the jury what an ekg is? >> sure, so an ekg is shorthanded for electrocardiogram. that is the test where you see people put the little stick dwl dwsticky things on the chest. what an ekg is an opportunity at the surface level of the chest but the technology is so fascinating, it can give you a glimpse into the heart itself to see a whole host of things including is there any evidence of any heart injury happening now or previously? and any abnormal heart rhythms? a whole host of other information that we can get from the ekg at that snapshot in time. and then sometimes what we'll do is repeat the ekgs down the line so we can compare and contrast and see if anything changed. >> so you looked at all of this medical information on mr. floyd
including the ekg. did you note any cardiac problems that related to mr. floyd? >> i noted no cardiac problems in the medical records as far as mr. floyd's medical condition was concerned, including everything i mentioned, ekg, even a time where they put him on a continuous cardiac monitor which they'll do sometimes just to see beat to beat if anything is going on and i reviewed that as well. >> did you see any evidence of mr. floyd having had any abnormal heart rhythms? >> his ekg showed absolutely no abnormal heart rhythms. the cardiac telemetry i mentioned that he had on for a few days, it did have on rare occasion something you call a pvc which is a very normal finding. i don't know if anyone ever felt it flutter for a second. it happens to all of us. but absolutely no ventricular
arrythmias for the duration of the time he was on the monitor. >> and pvc is not a plastic pipe. >> no. premature ventricular contraction. people refer to it as a skipped beat. a really normal phenomenon. if you drink a little coffee or anything else, you're sleep deprived, it's totally normal. nothing you should be concerned about if you feel that from time to time. >> did you find any evidence that mr. floyd had any negative heart condition? >> there was absolutely no evidence to suggest that at all. >> dr. rich, isn't high blood pressure an abnormal heart condition? >> so thank you for that question. i think that's an area of confusion sometimes. so high blood pressure in and of itself is not a heart condition. high blood pressure occurs for
basically two reasons. number one, high blood pressure originates in the blood vessels of our bodies. oftentimes it is genertically termed. if you have a strong heart, you can also generate high blood pressures and so those two in combination. so why -- i'll pause there and can explain more. >> did mr. floyd have a strong heart? >> so every indicator is that mr. floyd had actually an exceptionally strong heart. he was able to generate pressures of upwards of 200 millimeters of murcury on some occasions. we talked a little earlier about my role as a heart transplant cardiologist. one of the problems with patients when they need a heart transplant is the exact opposite. their hearts are so weak they can't generate a high blood pressure. the top number might be 80.
the reason why high blood pressure though is important and it is important to treat high blood pressure is because over time if high blood pressure goes untreated, 10, 20, 30 years, the impact of that high pressure on the heart can eventually start to become a bit of a problem. so the way i explain it to my patients who come into the office and i talk to them about treating their high blood pressure, is i say remember the heart is a muscle. so if you go to the gym and you pick up a couple of dumb bells and you start to lift the weights, initially it feels fine. in fact, you probably get a little stronger. your heart -- excuse me, the muscle will likely get even a little thicker, a little bigger which is exactly what it is supposeded to do. and initially that might actually be a really good thing. but if i came back, you know, ten years later and said how is it going? you'd say, man this is getting pretty tough. and then the muscle can start to
tire out. so we do want to treat high blood pressure. i can't emphasize that enough. high blood pressure should be treated. but high blood pressure in and of itself is not a heart condition. >> so we talked about your review of the medical records. you also looked at video footage in forming your opinions. can you tell us what you were looking for in the video footage that you examined? >> sure. >> so my approach to the video initially was sort of similar to my approach of the medical records. meaning, i wanted to just do some cursory inspection, observation, basic stuff. what did mr. floyd look like? was mr. floyd talking? and was he talking clearly? answering questions appropriately? did i notice any evidence of
abnormal physical exams on the video actually? i was trying to look for as well. when mr. floyd was walking, did he appear like he was walking without difficulty or was it looking like he was perhaps with low blood pressure and maybe going to fall down? i was listening for any opportunity i could to hear him say i'm having chest pain or the palpatationses or fluttering sensations. but basically doing what i do when i assess any person for a possible medical problem. i was looking for any and all of those possible subtle signs. >> so this is video footage from mr. floyd's encounter of may 25th of last year? >> that's correct. >> were you focused on things that would give you any insights into his ability to breathe? >> yes. of course.
>> so the chest wall which i'll show with you my hands here, basically makes up the bones and the muscles of the entire rib cage. and it might have been explained previously to you. but the chest wall and the muscles and how they interact along with the diaphragm muscle inside are the key structures that the deferment if someone is able to take in enough air and able to get enough out. so if there is -- for example, the lungs can be working okay, but if the chest wall is diseased, if the muscles associated with the chest wall aren't able to contract and move and do their job, enough oxygen can't get in that way either. >> so, doctor, in our covid-19 world, do you make clinical assessments of your patients? in your work life by video?
>> yes, that is actually one of the trans formation that's we have needed to adapt to this past year. we're getting back to now seeing most of our patients in person. but during the course of this pandemic, to minimize exposures, we set up a bunch of the video visits with patients. what came to appreciate is there is no substitute to actually putting your hands on a patient, that is still preferable in my opinion to really examine them closely, you can get a lot of information off of a video assessment even physical examination by looking at -- have them turn the neck to the side and see the neck veins which is an indicator of pressures. i can see the legs to see if there is any indication of swelling which may be congestive heart failure. i can see how thaur talking and if they seem breathless or short of breath. so we have found out that we can do a lot via video assessments.
>> were you able to then see mr. floyd appear at a time after he was first approached by the police on may 25th, 2020? >> yes. >> what were your observations about mr. floyd from in a initial encounter with the police? >> so from his initial encounter, remembering particularly when he was asked to get out of his car, he appeared fearful. but was speaking clearly. he was answering questions appropriately. didn't see any acute distress. i saw no indicators at that time that he was suffering from low oxygen, for example, or from any active medical problem and as i said, you was really trying to keep a close eye on some of the subtleties of his appearance and speech and so forth. >> were you able to observe at the point he was asked to get into the squad car? >> yes, i was.
>> what were your observations with respect to that period of time? >> i watched him walk to the squad car and then observing an interaction where they were asking him to get into the backseat of the car. i heard him talking about how he was claustrophobic. there were times he was being pushed into the car. he even made indicators at that time that he couldn't breathe. but all of my observations at that point were still that up until the point that he was kind of getting pushed or pulled through the car and ultimately on to the pavement, up until that point, i also saw no evidence that there was anything active going on from a cardiac standpoint. >> and what sort of active thing
might you be looking for over that period of time? >> for example, let's say he was having, you know, arrythmia and abnormal heart rhythm? especially if originating from the heart. oftentimes what will happen is you have the heart rhythm that goes abnormal and you go from being totally fine, like hopefully we all here today to instantly dizzy or passing out. >> i didn't see any indicators that is happening. i didn't hear him complaining of dizziness or fluttering of the chest. i couldn't see any swelling in his body. again, i didn't want to take anything for granted that even from the initial encounter up until that point what if something developed from point a to point b? and so again, up until that point, i saw no indicators of low blood pressure, or anything else abnormal with the heart. >> turning then to the restraint on the ground that you were referring to, what were your observations then as a cardiologist from your having
viewed mr. floyd's restraint on the ground by mr. chauvin? >> sure. so my observations were that he was restrained in a life threatening manner being specifically my observations was that he was on the ground in the prone position. handcuffed, hands behind the back. a knee on the back of his neck. a knee on the back of his bumper torso or shoulder. hands pushing his handcuffed hands up into his chest. i observed a knee compressing his -- i thought it was his but of course buttocks or upper thighs and lower extremities being pinned down to the ground. so that my initial observation was what is the position first and foremost he is being subjected to? >> and did you see at some point
in watching the video a that mr. floyd went into cardiopulmonary arrest? >> eventually, yes, i did. >> do you know what mr. floyd's heart rhythm was when he was taken from the scene? >> well, so in the course of the restraint, i was looking to see if his deterioration occurred rapidly, like i was just talking about, for example, the primary cardiac event. the most common arrythmia is what we call ventricular fibrillation or vf for short. when that happens, the individual will look relatively okay, meaning, they're alert, they're talking, and then they will immediately become unconscious. on the other hand, if the cause of the cardiopulmonary arrest is
from something else, for example, low oxygen levels, you will typically see that deterioration happening much more gradually and slowly. so my observations were the second that you can see at least i could see his speech starting to become less forceful. his muscle movements becoming weaker. until, of course, eventually his speech became absent. eventually his muscle movements were absent. and then as we later discovered by the heart rhythm, he was in a pea cardiopulmonary arrest. >> so i'd like to talk with you about two concepts. the one being p.e.a.
pulse. >> ventricular fibrillation is the heart rhythm looking like this. there is nothing else going on. pulseless electrical activity, if you are a clinician, a doctor, or a nurse or anyone for that matter who ever been trained in cardiac arrest, one of things that will come to mind immediately is whenever you see a p.e.a. arrest, you need to think about what's causing it. because nearly all p.e.a. arrests are being caused by something relatively specific and if you can identify what that is, it can be reversed. >> what is the most common cause of p.e.a.? >> so you might have heard of others talking about the hs and the ts. so one of those hs, the most common cause for a p.e.a.
cardiopulmonary arrest is hypoxia. low oxygen levels. >> and what about asystole? >> that is the flat line. so, you know, when any human dies, they will eventually go into asystole where there is absolutely no heart rhythm occurring. even this chaotic rhythm. that is, again, sometimes called a flat line. so v fib is this thing, p.e.a. can have chaotic looking rhythms without a pulse and asystole is the absolute absence of any cardiac article activity. >> if mr. floyd is in a p.e.a. state or generally anyone, is
p.e.a. reversible? >> so it is important to put it into context. so we see p.e.a. cardiac arrests in the hospital all the time. whenever you see a p.e.a. cardiac arrest, you rush to it, of course, and you begin the protocol and that protocol is hs and ts. so you give oxygen. if you don't think they have enough oxygen. that is the most critical thing to do. depending on the other hs, for example, hypovolemia or hemorrhage, if you think they're bleeding out from a trauma, rush and give them blood. so we resuscitate people with p.e.a. not infrequently. unfortunately, p.e.a. can also be a devastating cardiac arrest and despite all of our best abilities sometimes it's not reversible.
>> dr. rich, did you see any evidence at all that george floyd had a heart attack? >> no. none whatsoever. >> what about this notion of something called a silent heart attack? >> a silent heart attack? well, so silent heart attack, you know, a silent heart attack is sometimes referred if it looks like he may have had a heart attack but there were no clinical signs to suggest it. it's a relatively uncommon finding. one of the problems with diabetes is you lease sensation in the nerve endings. and so typically when you're having a heart attack, you'll see people clutch their chest. oh, my god, i'm having chest pressure, chest pain. sometimes diabetics won't have that. it's possible they can have a silent heart attack. but there was no evidence that mr. floyd had any type of heart attack, a silent heart attack or
n nonsilent heart attack. >> you talk about cardiac arrythmia. the fluttering of the heart. i think you referred to it as the hs and ts. >> when somebody is suffering from ventricular fibrillation or t tachicardia, is that sud snen. >> yes, it can certainly cause said encardiac death. kit be described as that. >> again, in viewing mr. floyd and his encounter on the videos of may 25th, did mr. floyd die a sudden death? >> mr. floyd died a gradual
death. it would not be considered the classic sudden death from the standpoint of how you're putting into that context. meaning, when people have that ventricular fibrillation, that vf arrest, this he go from being fine one moment to completely out the next. i don't know what happened. i was sitting next to him and he keeled over and was on ground. and that could have been a vf arrest. so sometimes there is symantecs in terms of this. but in the case of mr. floyd, yes, he did have a cardiopulmonary arrest. but, no, there was no evidence of a sudden cardiac death from the v fib or any other malignent heart arrythmia. >> all right. we talked about your view of the medical records and we talked about your review of the video. the their thing you said was the
autopsy report and findings. what were you looking for with respect to the autopsy report and findings? >> sure. we're talking about the autopsy report here towards the end. i looked at the autopsy report first. i went back to the autopsy again. what i was looking for in the autopsy is first of all, everything. when we get an autopsy, often times you'll get it because you're looking -- could there be something we weren't aware of that could have happened? but in addition to looking at all the findings, my major focus, of course, as a cardiologist, was anything and everything related to the heart. >> what did you find? >> you know, it's interesting. i think what was most important was not only what i found but what i did not find. so what i found was that his heart architecturally looked
normal. he had a description of coronary artery disease which i found notable. >> i found it notable but not unusual because unfortunately coronary artery disease is so common. i mean statistically, not to scare anybody, many of us in this room likely have coronary artery disease. i looked at whether there was any evidence whatsoever that mr. floyd could have had a heart attack based on autopsy. so when i looked at those arteries around the heart, i not only looked to see how narrow they were and what the composition of that narrowing was, but also whether there was any platelets or clotting factors or anything else of that nature in the arteries which is
what would be there if there was a heart attack. >> and then did you see evidence of the platelets as you would expect to see in mr. floyd had had a heart attack? >> no. there were no description of any of the platelets or clotting factors or anything that would block off an artery. none of the arteries were totally -- were often used blocked off which is what happens in a heart attack. >> i want to ask you about some of your specific findings in this regard. but first, for the jury, would you just tell them whether you excluded coronary artery disease as a cause of mr. floyd's death? >> yes. i have excluded that with a high degree of medical certainty. >> now you talked about looking for evidence of platelets from the autopsy report and that you would expect to have seen those if he had died from a heart attack and you didn't see them. >> right. >> what else did you see? >> well, so what i also saw was i looked at the heart muscle
itself. so not only did the heart muscle itself not show any evidence of any injury at all which you would see, like, you mentioned the silent heart attack? what about a few years ago somehow he had a mini heart attack. you would see evidence of that in the heart. you would see a scar tissue, et cetera. so not only did i not see any evidence of a heart attack, the pathologist did it very good job in my opinion actually of describing what is called the endocardium. that is the inner most lining of the heart. and that is the most susceptible part of the heart to cardiac injury. even the smallest of heart attacks will always originate on that endocardium. it was not only described as normal, it was described as smooth and glistening.
a completely normal finding. no evidence at all of even small microscopic injury. >> were you able by your looking at the autopsy report on the heart to tell whether there is any evidence as to whether mr. floyd had ever had a heart attack even going back into the past? >> no evidence whatsoever of a previous heart attack. >> doctor, what is aschema? >> so aschema is a reduction in blood flow to any organ of the body that could be the heart, it could be the kidney. that can lead to basically insufficient delivery of oxygen for a short period of time. and if aschema continues to occur for long enough, that can sometimes cause irritability in that organ. it's important to distinguish it
from infarct. that is what we mean when we say a heart attack. -- excuse me, a heart attack. when a marathon runner goes on a run, their muscles will get temporarily aschemic. when we live muscles in the gym and we talk about feeling the burn, that means you are feeling lactic acid build up and it's -- that's what that is. >> any evidence of that? >> not in the autopsy, no. >> let's talk about the arteries and the plaque that was in the arteries. were you able then to eliminate the blockage in the arteries as a contributing cause of mr. floyd's death? >> yes. i would like to clarify. i saw no blockages, i saw no complete blockages. there were narrow ones. there were narrowings in more than one blood vessel.
importantly, the main coronary artery, the left main coronary artery, there was no zriction of any narrowings or disease in the left main coronary artery. >> why is that, sir? >> well, because that very first pathway that blood travels down that branch off into multiple other arteries. so left main disease as we sometimes call it in cardiology is among all of the vessels, probably the highest risk blood vessel if it were to get blocked off. >> so how would you characterize the nature of the plaque within the artery? was it soft, was it fractured? how would you characterize it? >> i would characterize it the way that the medical examiner characterized it. i'm not an expert at characterizing plaque at a
microscopic detail but i appreciated the description of what seemed to be not only relatively conventional looking artery narrowings, plaque buildup that we all will eventually get in our arteries, but also in one of the arteries, it was described that there was an element of calcium, and i only mention that because that also indicates that this coronary artery disease didn't just kind of develop right away. it was probably the slow gradual buildup of the narrowings, and that actually is a very clinically relevant finding in the field of cardiology. >> doctor, did you make any assessments around the size of this mr. floyd's heart? >> yes, i did. >> would you tell the jury about that? >> sure. so when looking at the size of his heart, not just the size, but the thickness of the heart, it was described as being mildly thick or mildly enlarged.
now, depending on which criteria you use, one criteria would agree with that, that it was mildly thick or enlarged. others would suggest that it was in the normal range. i do believe that it was likely mildly thick, and mildly enlarged. it is an expected finding in somebody that has high blood pressure. so even though there are some scoring systems that might say it wasn't even enlarged at all, in my view as a cardiologist i do believe there was just the smallest element of increased heart thickness. and as i mentioned before, that's important because that's exactly what the heart is supposed to do when there's high blood pressure. that is a normal response. the muscles getting stronger, it's allowing the heart to work and work well. now, if that goes on for, like i said before, 20 years, we can have problems.
but early on having a mildly thickened heart is not only a normal finding in someone with high blood pressure. it may actually be beneficial in the short term. >> doctor, putting all this together, did you see any evidence at all that the primary cause of mr. floyd's death originated in his heart? >> no, i did not. >> let's talk about a new subject. whether or not mr. floyd suffered from a drug overdose and died from a drug overdose. >> okay. >> that was something that you also considered as a cause? >> yes, sir. >> were you or are you familiar with mr. floyd's toxicology results? >> yes, i am. >> what -- or which substances did you consider in evaluating mr. frloyd toxicology history? >> when i looked at the
toxicology reports i focused mostly on the finding of fentanyl as well as the finding of methamphetamines. >> what role, if any, do you feel that the fentanyl played in the cause of mr. floyd's death? >> as far as i can tell from reviewing all of the facts of the case i see no evidence at all to suggest that a fentanyl overdose caused mr. floyd's death. >> as cardiologist do you occasionally have to care for patients who struggle with opioids or opioid addiction? >> absolutely. >> so here you found that the fentanyl in your opinion played no role in mr. floyd's death, would you tell us why it is you hold that opinion? how do you reach that conclusion? >> well, i think i would break it down to just two major reasonings, number one it appeared to me that mr. floyd, who was an acknowledged frequent
chronic user of substances, particularly opiates, likely developed a high degree of tolerance. there's even one emergency room visit that i had reviewed where he came in and he told me the emergency room team that, you know, he was tearful and says i'm having trouble with substance abuse. i just took -- i think he said i took eight percocets within two hours. he had no side effects from that at all. they observed him for a couple hours and discharged him. looking through it looked like he had built up a high tolerance in general to opiates. but the second and just as important, maybe more important, was i didn't see any of the signs of an opiate overdose when i reviewed the videos. >> and when you -- referring to the signs of an opiate overdose, would you tell the jurors or describe for them what are those signs and what didn't you see? >> sure.
so in my experience in the intensive care unit, taking care of patients who come in with an opiate overdose, first of all they are usually extremely lethargic. oftentimes nearly unarousable and you try to wake them up and they're falling right back asleep. they're not talking to you, if they are talking to you they're often having slurred speech. if they're standing up, which they wouldn't be if they had a fentanyl intoxication, an overdose. they would have to get pretty dizzy pretty quickly. i saw the opposite with mr. floyd. i saw that he was alert. he was awake. he was conversant. he was walking and yet according to the toxicology report he had this degree of fentanyl in his system. so just looking at the clinical story i didn't see any signs or
symptoms of fentanyl overdose. >> let's turn to methamphetamine then. what role do you feel that methamphetamine played in mr. floyd's cause of death? >> i feel it played no substantive role at all. >> and why is that? >> well, all considering it was very relatively low level of methamphetamine in his system and so when you look at the context of the case, and you see a relatively low level of methamphetamine in the context of everything else, i felt very confident that that load degree of methamphetamine was not what was triggering this profound cardio pulmonary arrest and ulti ultimately p.e.a. arrest. >> so doctor, taking into account all of the evidence that you reviewed do you have an opinion to a reasonable degree of medical certainty as to
whether mr. floyd's death was preventable? >> yes, i do. >> would you tell us what that opinion is? >> yes, i believe that mr. george floyd's death was absolutely preventable. >> were there critical points in time during his subdual and restraint on the ground when you feel measures could have or should have been taken that would have preserved his life? >> yes, i do. i think there were several junctures, actually. >> would you tell us about those? >> sure. the first, of course, was to not subject him to that initial -- that initial prone restraint positioning that he was subjected to. that is first and foremost. so if that was not the case, i don't think he would have died. the second, though, was when he was in that subdual and restraint positioning, and he
was stating repeatedly that he can't breathe. and he was getting a little weaker in his speech. there was one moment in the video where i heard one of the officers saying i think he's passing out. that would have been an opportunity to quickly relieve him from that position of not getting enough oxygen, perhaps turn him into a recovery position and allow him to start to expand his lungs again and bring in oxygen and get rid of carbon dioxide. so in addition to not putting him in that position in the first place when there were signs that he was worsening, repositioning him, i think very likely would have also saved his
life. >> was there a point in time, dr. rich, when mr. floyd was checked for a pulse when he was in the subdual and the restraint of mr. chauvin? >> yes, yes there was. >> at the time that he was checked for a pulse and he no longer had one, in your opinion as a cardiologist was there anything mr. chauvin could have done at that point in time that would likely have saved mr. floyd's life? >> objection, leading. >> sustained. >> well at the time that mr. floyd is determined to have not had a pulse, what is your opinion to a reasonable degree of medical certainty as to what mr. chauvin may have done that would have potentially saved his life? >> objection, calls for speculation. >> overruled, you can give an opinion. >> well, just prior to that point i heard one of the